Новый эндоскопический манипулятор Naviot® облегчает проведение видеоторакоскопии без ассистента

Received 2 March 2005; received in revised form 29 April 2005; accepted 2 May 2005

*Corresponding author. Tel.: +81㫴��? fax: +81㫴��?.

E-mail address: iyoshino@surg2.med.kyushu-u.ac.jp (I. Yoshino).

Abstract

A novel endoscopic device consisting of a one-touch manipulator and an automatic microzoom function, called Naviot® (Hitachi Co., Japan), enabled a solo-surgery in thoracic sympathectomy.

Key Words: Video-assisted thoracic surgery (VATS); Endoscope manipulator; Solo-surgery

1. Introduction

Video-assisted thoracoscopic surgery (VATS) has recently gained widespread popularity because of its minimal invasiveness to patients. As thoracoscopic devices continue to develop, the number of general thoracic surgery procedures that can be performed have been facilitated under VATS. However, a training in team skills is required for such endoscopic surgery since a surgical view of an operator is very limited in the scopic view, which is manipulated by an assistant. Discordance between the operator and assistants leads to stress in surgeons, and to an operative risk.

Recently, to minimize the above problems, a novel manipulator system was developed [1]. The system consists of an endoscope manipulator using a five-bar linkage mechanism and an automatic microzoom endoscope, called Naviot® (Fig. 1). We introduced Naviot in thoracoscopic thoracic sympathectomy for two patients with palmer hyper hydrosis. (ладонный гипергидроз, повышенная потливость ладоней)

1.1. The manipulator system (Naviot®)

The manipulator is based on a five-bar linkage mechanism that has two independent motors on the bottom. Also, a zoom-up mechanism of the endoscope was applied to this manipulation system. Electrical devices, such as motors, were set below the operative stand. The moving range was approximately 25 degrees for both vertical and horizontal directions. Operations were performed using the conventional endoscopic surgical devices under the thoracoscopic view and controlled by the manipulator. The thoracoscopic view was superimposed by a navigating circle and bar on the video image. Two thumb-buttons were attached on the holding area of the forceps. By pressing these buttons the operator could control the optical zoom and the direction of the endoscopic movement. A zoom-up vision was ob-tained by turning on the zoom-up circle with a thumb-button in the operator’s hand without the back-and-forth movements of the scope. Turning on the navigating circle and bar with the other thumb-button led the thoracoscope toward the indicated direction (Fig. 1, Video 1).

Video 1. The moving range of this manipulator is approximately 25 degrees for both vertical and horizontal directions. The thoracoscopic view was superimposed by a navigating circle and bar on the video image. Two thumb-buttons were attached on the holding part of the forceps. By pressing these buttons the operator could control the optical zoom and the direction of the endoscopic movement. A zoom-up vision was obtained by turning on the zoom-up circle with a thumb-button in the operator’s hand without the back-and-forth movements of the scope. Turning on the navigating circle and bar with the other thumb-button led the thoracoscope toward the indicated direction.

1.2. Clinical summary

The manipulator system was introduced for the thoracic sympathectomy for two patients, a 17-year-old woman and a 45-year-old man who were diagnosed with hyper hydrosis.
Under general anesthesia, the patients were placed in a semi-Fowler position, and 3 access ports including the 4th intercostal space (ICS) on the middle axillary line, the 5th ICS on the middle axillary line and the 5th ICS on the anterior axillary line. For the right side, a solo-surgery was achieved using the manipulation system, and for the left side, conventional VATS was performed by two surgeons. For both sides, a conventional thoracoscope inserted to the 5th ICS on the anterior axillary line was attached to the manipulator.

Complete resections of the 2nd to 3rd sympathetic ganglions were smoothly performed in both sides of the patients. The Naviot® system worked well especially in stability and shift of the endoscopic view. Operative period and estimated blood loss of the right side were equivalent to the left side in both patients (Table 1). The patients did not complain of wound pain around the thoracoport during videoscopy of both sides. Chest tubes were removed on the following day, and the patients discharged within 4 postoperative days.

Table 1 Operative results of two patients with hyper hydrosis

2. Discussion

Naviot® is such a unique system consisting of an endoscopic manipulator and a zoom-up function, and of a one-touch controller button, that it achieves stabilization and easy manipulation of endoscopy, and a high quality image. Naviot was first reported as a laparoscopy-manipulator [2].
For such an operation as a thoracic sympathectomy, one surgeon could manipulate the endoscope as well as handling two endoscopic instruments. In the manipulation of endoscopy, the change of endoscopic view was well coordinated with the surgeon’s intent, therefore, stress on the surgeon was minimized even though no assistant attended. In VATS within 3 access ports such as extirpation of mediastinal or chest wall tumor, and bullectomy of the lung, a solo-surgery is easily performed using this manipulator system. Otherwise in more complex VATS like a lobectomy, the merit of the manipulator is not so expected since a surgical field cannot be covered by the range of view of the manipulator, then, multiple set-up is required.

Acknowledgments

We thank Mr Kunio Ooyma for the development of the Naviot system, and Drs Masafumi Yamaguchi and Toshifumi Kameyama for clinical assistance.

References

Kobayashi E, Masamune K, Sakuma I, Dohi T, Hashimoto D. A new safe laparoscopic manipulator system with a five-bar linkage mechanism and an optimal zoom. Comp Aid Surg 1999;4:182��.[CrossRef]
Yasunaga T, Hashizume M, Kobayashi E, Tanoue K, Akahoshi T, Konishi K, Yamaguchi S, Kinjo N, Tomikawa M, Muragaki Y, Shimada M, Maehara Y, Dohi Y, Sakuma I, Miyamoto S. Remote-controlled laparoscopic manipulator system, NaviotTM, for endoscopic surgery. Int Congr Ser 2003;1256:678��.[CrossRef]

Комментарий:

Не вдаваясь в суть процедуры мы не можем не прокомментировать результаты клинического применения нового устройства. Авторы применяли его у 2-х пациентов страдавших ладонным гипергидрозом (повышенной потливостью ладоней) для проведения симпатэктомии. Нас поразило, что в Японии (по крайней мере в этой клинике) данную операцию делают в 2 этапа, и что операция продолжается больше часа. В нашем центре операция по лечению гипергидроза (повышенной потливости) всегда делается за один раз, причем операция занимает не более 20 минут, что в 3 раза быстрее, чем авторы оперируют с одной стороны. Поразительно, не всегда нужны высокие технологии, чтобы добиться хороших результатов.

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